FERTILITY AND STERILITY
Vol. 58, No.4, October 1992 Printed on ocid-{ree paper in U.S.A.
Copyright C> 1992 The American Fertility Society
Hysteroscopic treatment of congenital uterine malformations causing hemihematometra: a report of three cases Jurgen Hucke, Dr.Med.*t Filip DeBruyne, Dr .Med. * Rudi Ludwig Campo, Dr.Med.:\: Ahmed Abou Freikha, Dr.Med.* Heinrich Heine University Dusseldorf, Dusseldorf, Germany, and Institute for Fertility Diagnostics aVF-ET), Leuven, Belgium
Congenital uterine malformations may cause different forms of disorders. Most common is the septated uterus that is associated with an increased rate of fetal wastage. Today, the traditional form of transabdominal metroplasty is being replaced by the hysteroscopic approach using the resectoscope (1) or the Nd-YAG laser (2). In rare cases, uterine anomalies may occur as septate uterus or uterus bicornis with one noncommunicating side causing a hemihematometra. At adolescent age, increasing dysmenorrhea will occur with menarche. The underlying uterine malformation may remain undiagnosed because the communicating side of the uterus is producing menstrual flow. The hemihematometra enlarges, and a pelvic mass is being formed. This may lead to explorative laparotomy in which the unexpected situation is found and sometimes badly handled. We report three cases of uterine anomalies with one-sided occlusion causing hemihematometra. Two of them had been unsuccessfully operated years ago by laparotomy. Now they were successfully treated with the hysteroresectoscope. CASE REPORTS
cating hematometra of an uterus bicomis. The hemihematometra was incised, and an artificial passage to the cervix was created by blunt dissection. In 1989, the patient was referred to Us because of increasing pelvic pain. A diagnostic hysteroscopy showed a left uterine cavity shaped as a uterus unicornis. Simultaneous laparoscopy revealed a uterus bicomis with two completely separated uterine bodies and a common cervix. The right fallopian tube was absent (Fig. 1). The way into the right hom was dissected with a 9-mm hysteroresectoscope (Storz Company, Tuttlingen, Germany) by a cutting needle that we commonly use for septum dissection. A pyometra was found and flushed. The passage to the cervix was widened with a cutting loop as used for myoma resection. Having no reproductive potential, the endometrium in the right uterine hom was ablated with the resectoscope. The postoperative course was uneventful. The patient was afebrile, and microbiological cultures were sterile. In a 3-year follow-up, the patient has had no recurrence of hematometra. Recent ultrasound (US) investigation did not show endometrial lining or liquid retention in the right uterine hom.
Case I
In 1982 a 14-year-old patient had an explorative laparotomy because of a painful pelvic mass. This tumor turned out to be a right-sided noncommuniReceived January 2, 1992; revised and accepted June 25, 1992.
* Department of Obstetrics and Gynecology, Heinrich Heine University Dusseldorf. t Reprint requests: Jurgen Hucke, Dr.Med., Frauenklinik der Heinrich Heine Universitat, MoorenstraJ3e 5, D 4000 Dusseldorf 1, Germany. Institute for Fertility Diagnostics (IVF-ET).
*
Vol. 58, No.4, October 1992
Case 2
The 16-year-old patient was referred to us because of increasing severe primary dysmenorrhea. Vaginal ultrasonographic examination revealed a left-sided endometrial echo, a large horizontal uterine diameter, and a smallll-mm echo-free zone in the right part of the uterus. A uterine malformation in the form of a uterus septus with noncommunicating right hom was suspected. The diagnosis was confirmed by laparoscopy showing a single-bodied broad Hucke et aI.
Communications-in-brief
823
Figure 1 case 1.
Uterus bicomis with noncommunicating right hom-
uterus with a palpable medial impression. The right fallopian tube was only formed rudimentary without a fimbrial opening. Hysteroscopy showed a left uterine cavity in the form of a uterus unicornis (Fig. 2). The complete medial wall of the left cavity was widely dissected using a 9-mm resectoscope with a cutting needle. The intrauterine surgery was monitored by single-puncture laparoscopy to prevent perforation. Intermittent transabdominal ultrasonography was used as a second safety measure to define the spatial relation between the hysteroscope and the occluded cavity. The area of dissected myometrium was four times larger than the original left uterine cavity. In the right fundal part of the uterus, the small suspected zone of endometrium revealing the rudimentary right uterine horn was found. It was filled with blood and under tension. The endometrium was ablated. For future reproduction we inserted an intrauterine device (IUD) to keep the newly built, large uterine cavity open. Intraoperative and postoperative bleeding was tolerable. The hemoglobin count decreased from 14.1 gjdL preoperative to 12.8 gjdL 5 days postoperative. No vasoconstrictive drugs or intrauterine compressive agents were used. The IUD was removed 4 months later during a control hysteroscopy. It showed approximately 90% reocclusion of the dissected myometrium with only a small recessus left open. The original left cavity was shaped normally and free of synechia. The patient now is completely free of dysmenorrhea. Ultrasound control did not show any fluid retention in the uterus.
appendix vermiformis." Morphological examination of the myoma revealed blood retention and endometriallining. Retrospectively, it must have been a right horn of a misshapen uterus bicornis. The following years the patient suffered from chronic pelvic pain. Extensive pelvic adhesions were found and removed by laparotomy in microsurgical technique. A control laparoscopy showed a pelvis free of adhesions. Nevertheless, the patient still had the same type of pelvic pain. It was considered to send her for psychological exploration because no organic cause for the pain could be found. We saw the patient in March 1991. Vaginal US investigation showed a 5-mm echo-free area in the right fundal part of the uterine body. Regarding the preoperative history, a small hemihematometra was suspected. Hysteroscopy showed a left uterine cavity shaped as a uterus unicornis. Laparoscopy revealed a broad but symmetric uterine body with a small medial impression (Fig. 2). In the same manner as reported in case 2, the complete medial wall of the cavity was transsected with the resectoscope. A small, blood-distended cavity with endometrial growth was found. The endometrium was ablated. The ablation in the upper part of the cavity was difficult because hardly any myometrial cover was present because of the previous operation in 1979. Nevertheless, uterine perforation could be avoided as in the two other cases. From the following day on, the pain that the patient had experienced for years had disappeared. A repeat hysteroscopy after 2 months showed the left uterine cavity free of synechia. The medial wall that had been incised by hysteroscopy was already well healed and covered by endometrium. Ultrasonography did not show any fluid retention. In a 15month follow-up, the patient has been free of pelvic pain.
Case 3
In 1979, a 14-year-old patient had a laparotomy under the suspected diagnosis of appendicitis. During the operation "a huge myoma on the right side of the uterus was encountered and removed with the 824
Hucke et al.
Communications-in-brief
Figure 2 Uterus septus with rudimentary right cavity-cases 2 and 3 (patient 3 right tube being removed before).
Fertility and Sterility
DISCUSSION
Uterine malformations of the described form are rare. In 920 diagnostic hysteroscopies between 1989 and 1991 mainly because of infertility (including 72 patients with habitual abortions), we found 85 congenital anomalies (9.2%), 75 (8.2%) of them being uterus septus/subseptus. The described three cases represent only 0.3%. Symptoms such as pelvic pain usually begin with the onset of menses. A careful diagnostic work-up including US investigation should be essential to avoid unsuspected operative situations as had been encountered before in two of our three patients. Diagnostic hysteroscopy and laparoscopy can clarify the situation and should be considered before performing a laparotomy. Because we could show it is now possible to handle the situation completely by the endoscopic approach, the disadvantages of laparotomy (increased postoperative pain, risk of adhesion induction, longer hospitalization) can be avoided. Under the aspect of reproductive function, this may become an important factor for young women. When performing hysteroscopic intrauterine dissection, a controllaparoscopy in this type of metroplasty is very helpful to avoid perforation and injury to other organs such as bowel and bladder. In the two cases of uterus septus, the dissection had to be taken very far to the cranial-contralateral part of the uterine body. It should be considered not to resect in the depth of the paracervix; otherwise, a branch of the uterine artery could be opened. This might cause excessive bleeding. From our experience based on hysteroscopic treatment of myomas and septa, a wide dissection within the uterine body can be performed without fear of enforced postoperative
Vol. 58, No.4, October 1992
bleeding. We never apply vasoconstrictive drugs or postoperative intrauterine compressive agents. In all three cases, a reproductive capacity of the occluded side was not present. The endometrium was ablated in the rudimentary horn to prevent recurrence of hematometra. The attempt to keep the shape of the newly built uterine cavity open by insertion of an IUD, analogous to transabdominal metroplasty, failed. Nevertheless, control hysteroscopies showed the former uterine cavities without synechia. The aim of pain relief was reached in all three patients. SUMMARY
To our knowledge, this is the first case report of hysteroscopic treatment of congenital uterine malformations with one-sided occlusion causing hemihematometra. This rare form of uterine anomaly should be considered when symptoms such as increasing pelvic pain start with menarche. A 9-mm resectoscope was used for dissecting the way into the occluded part of the uterine body. There the endometrium was ablated for prevention of recurrence of hemihematometra. By this endoscopic approach the disadvantages of laparotomy could be avoided in three adolescent patients. Key Words: Mullerian anomalies, hematometra, operative hysteroscopy, resectoscope. REFERENCES 1. De Cherney AH, Russel JB, Graebe RA, Polan ML. Resectoscopic managment of miillerian fusion defects. Fertil Steril 1986;45:726-8. 2. Daniell JF, Osher S, Miller W. Hysteroscopic resection of uterine septi with visible light laser energy. Colposc Gynecol Laser Surg 1987;3:217-20.
Hucke et al.
Communications-in-brief
825
Vol. 58, No.4, October 1992 Printed on ocid-{ree paper in U.S.A.
Copyright C> 1992 The American Fertility Society
Hysteroscopic treatment of congenital uterine malformations causing hemihematometra: a report of three cases Jurgen Hucke, Dr.Med.*t Filip DeBruyne, Dr .Med. * Rudi Ludwig Campo, Dr.Med.:\: Ahmed Abou Freikha, Dr.Med.* Heinrich Heine University Dusseldorf, Dusseldorf, Germany, and Institute for Fertility Diagnostics aVF-ET), Leuven, Belgium
Congenital uterine malformations may cause different forms of disorders. Most common is the septated uterus that is associated with an increased rate of fetal wastage. Today, the traditional form of transabdominal metroplasty is being replaced by the hysteroscopic approach using the resectoscope (1) or the Nd-YAG laser (2). In rare cases, uterine anomalies may occur as septate uterus or uterus bicornis with one noncommunicating side causing a hemihematometra. At adolescent age, increasing dysmenorrhea will occur with menarche. The underlying uterine malformation may remain undiagnosed because the communicating side of the uterus is producing menstrual flow. The hemihematometra enlarges, and a pelvic mass is being formed. This may lead to explorative laparotomy in which the unexpected situation is found and sometimes badly handled. We report three cases of uterine anomalies with one-sided occlusion causing hemihematometra. Two of them had been unsuccessfully operated years ago by laparotomy. Now they were successfully treated with the hysteroresectoscope. CASE REPORTS
cating hematometra of an uterus bicomis. The hemihematometra was incised, and an artificial passage to the cervix was created by blunt dissection. In 1989, the patient was referred to Us because of increasing pelvic pain. A diagnostic hysteroscopy showed a left uterine cavity shaped as a uterus unicornis. Simultaneous laparoscopy revealed a uterus bicomis with two completely separated uterine bodies and a common cervix. The right fallopian tube was absent (Fig. 1). The way into the right hom was dissected with a 9-mm hysteroresectoscope (Storz Company, Tuttlingen, Germany) by a cutting needle that we commonly use for septum dissection. A pyometra was found and flushed. The passage to the cervix was widened with a cutting loop as used for myoma resection. Having no reproductive potential, the endometrium in the right uterine hom was ablated with the resectoscope. The postoperative course was uneventful. The patient was afebrile, and microbiological cultures were sterile. In a 3-year follow-up, the patient has had no recurrence of hematometra. Recent ultrasound (US) investigation did not show endometrial lining or liquid retention in the right uterine hom.
Case I
In 1982 a 14-year-old patient had an explorative laparotomy because of a painful pelvic mass. This tumor turned out to be a right-sided noncommuniReceived January 2, 1992; revised and accepted June 25, 1992.
* Department of Obstetrics and Gynecology, Heinrich Heine University Dusseldorf. t Reprint requests: Jurgen Hucke, Dr.Med., Frauenklinik der Heinrich Heine Universitat, MoorenstraJ3e 5, D 4000 Dusseldorf 1, Germany. Institute for Fertility Diagnostics (IVF-ET).
*
Vol. 58, No.4, October 1992
Case 2
The 16-year-old patient was referred to us because of increasing severe primary dysmenorrhea. Vaginal ultrasonographic examination revealed a left-sided endometrial echo, a large horizontal uterine diameter, and a smallll-mm echo-free zone in the right part of the uterus. A uterine malformation in the form of a uterus septus with noncommunicating right hom was suspected. The diagnosis was confirmed by laparoscopy showing a single-bodied broad Hucke et aI.
Communications-in-brief
823
Figure 1 case 1.
Uterus bicomis with noncommunicating right hom-
uterus with a palpable medial impression. The right fallopian tube was only formed rudimentary without a fimbrial opening. Hysteroscopy showed a left uterine cavity in the form of a uterus unicornis (Fig. 2). The complete medial wall of the left cavity was widely dissected using a 9-mm resectoscope with a cutting needle. The intrauterine surgery was monitored by single-puncture laparoscopy to prevent perforation. Intermittent transabdominal ultrasonography was used as a second safety measure to define the spatial relation between the hysteroscope and the occluded cavity. The area of dissected myometrium was four times larger than the original left uterine cavity. In the right fundal part of the uterus, the small suspected zone of endometrium revealing the rudimentary right uterine horn was found. It was filled with blood and under tension. The endometrium was ablated. For future reproduction we inserted an intrauterine device (IUD) to keep the newly built, large uterine cavity open. Intraoperative and postoperative bleeding was tolerable. The hemoglobin count decreased from 14.1 gjdL preoperative to 12.8 gjdL 5 days postoperative. No vasoconstrictive drugs or intrauterine compressive agents were used. The IUD was removed 4 months later during a control hysteroscopy. It showed approximately 90% reocclusion of the dissected myometrium with only a small recessus left open. The original left cavity was shaped normally and free of synechia. The patient now is completely free of dysmenorrhea. Ultrasound control did not show any fluid retention in the uterus.
appendix vermiformis." Morphological examination of the myoma revealed blood retention and endometriallining. Retrospectively, it must have been a right horn of a misshapen uterus bicornis. The following years the patient suffered from chronic pelvic pain. Extensive pelvic adhesions were found and removed by laparotomy in microsurgical technique. A control laparoscopy showed a pelvis free of adhesions. Nevertheless, the patient still had the same type of pelvic pain. It was considered to send her for psychological exploration because no organic cause for the pain could be found. We saw the patient in March 1991. Vaginal US investigation showed a 5-mm echo-free area in the right fundal part of the uterine body. Regarding the preoperative history, a small hemihematometra was suspected. Hysteroscopy showed a left uterine cavity shaped as a uterus unicornis. Laparoscopy revealed a broad but symmetric uterine body with a small medial impression (Fig. 2). In the same manner as reported in case 2, the complete medial wall of the cavity was transsected with the resectoscope. A small, blood-distended cavity with endometrial growth was found. The endometrium was ablated. The ablation in the upper part of the cavity was difficult because hardly any myometrial cover was present because of the previous operation in 1979. Nevertheless, uterine perforation could be avoided as in the two other cases. From the following day on, the pain that the patient had experienced for years had disappeared. A repeat hysteroscopy after 2 months showed the left uterine cavity free of synechia. The medial wall that had been incised by hysteroscopy was already well healed and covered by endometrium. Ultrasonography did not show any fluid retention. In a 15month follow-up, the patient has been free of pelvic pain.
Case 3
In 1979, a 14-year-old patient had a laparotomy under the suspected diagnosis of appendicitis. During the operation "a huge myoma on the right side of the uterus was encountered and removed with the 824
Hucke et al.
Communications-in-brief
Figure 2 Uterus septus with rudimentary right cavity-cases 2 and 3 (patient 3 right tube being removed before).
Fertility and Sterility
DISCUSSION
Uterine malformations of the described form are rare. In 920 diagnostic hysteroscopies between 1989 and 1991 mainly because of infertility (including 72 patients with habitual abortions), we found 85 congenital anomalies (9.2%), 75 (8.2%) of them being uterus septus/subseptus. The described three cases represent only 0.3%. Symptoms such as pelvic pain usually begin with the onset of menses. A careful diagnostic work-up including US investigation should be essential to avoid unsuspected operative situations as had been encountered before in two of our three patients. Diagnostic hysteroscopy and laparoscopy can clarify the situation and should be considered before performing a laparotomy. Because we could show it is now possible to handle the situation completely by the endoscopic approach, the disadvantages of laparotomy (increased postoperative pain, risk of adhesion induction, longer hospitalization) can be avoided. Under the aspect of reproductive function, this may become an important factor for young women. When performing hysteroscopic intrauterine dissection, a controllaparoscopy in this type of metroplasty is very helpful to avoid perforation and injury to other organs such as bowel and bladder. In the two cases of uterus septus, the dissection had to be taken very far to the cranial-contralateral part of the uterine body. It should be considered not to resect in the depth of the paracervix; otherwise, a branch of the uterine artery could be opened. This might cause excessive bleeding. From our experience based on hysteroscopic treatment of myomas and septa, a wide dissection within the uterine body can be performed without fear of enforced postoperative
Vol. 58, No.4, October 1992
bleeding. We never apply vasoconstrictive drugs or postoperative intrauterine compressive agents. In all three cases, a reproductive capacity of the occluded side was not present. The endometrium was ablated in the rudimentary horn to prevent recurrence of hematometra. The attempt to keep the shape of the newly built uterine cavity open by insertion of an IUD, analogous to transabdominal metroplasty, failed. Nevertheless, control hysteroscopies showed the former uterine cavities without synechia. The aim of pain relief was reached in all three patients. SUMMARY
To our knowledge, this is the first case report of hysteroscopic treatment of congenital uterine malformations with one-sided occlusion causing hemihematometra. This rare form of uterine anomaly should be considered when symptoms such as increasing pelvic pain start with menarche. A 9-mm resectoscope was used for dissecting the way into the occluded part of the uterine body. There the endometrium was ablated for prevention of recurrence of hemihematometra. By this endoscopic approach the disadvantages of laparotomy could be avoided in three adolescent patients. Key Words: Mullerian anomalies, hematometra, operative hysteroscopy, resectoscope. REFERENCES 1. De Cherney AH, Russel JB, Graebe RA, Polan ML. Resectoscopic managment of miillerian fusion defects. Fertil Steril 1986;45:726-8. 2. Daniell JF, Osher S, Miller W. Hysteroscopic resection of uterine septi with visible light laser energy. Colposc Gynecol Laser Surg 1987;3:217-20.
Hucke et al.
Communications-in-brief
825
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